Vets seeking care died in VA limbo

In 2010, the Veterans Administration rolled out a new online application that promised the nation’s veterans a quick, easy way to access one of the chief benefits of military service: enrollment in the VA’s vast network of hospitals and health care facilities.

Veterans across the country responded.

In fact, the online system did the opposite of what it promised, an investigation by The Atlanta Journal-Constitution has found. Instead of making it easier and faster to apply for benefits, the online system sent some veterans who used it into administrative limbo where their applications received no action, delaying their access to health care.

By July 2012, the backlog of veterans whose applications were in so-called pending status had grown to 848,699, according to an internal VA analysis. VA’s backlog of pending health care applications had festered for more than a decade, and the new online applications made the problem worse.

As part of that review, a program analyst based in Atlanta discovered a troubling revelation: As many as 47,786 veterans whose applications languished in the pending application pool had died, according to the VA’s own records of deceased servicemen and women. Had any of them died because they failed to gain access to VA health care, the analyst wondered?

Alarmed by her findings, she said she prodded her superiors at the VA to solve the crisis in pending applications and fix the online system. Instead, the superiors ignored her warnings, she said, and continued to tell veterans that the online application was the fastest, easiest way to apply for VA health care.

“They lied to veterans,” said Kimberly Hughes, who oversaw the Health Eligibility Center’s informatics division that conducted the internal analysis of the pending applications. “They lied to Congress.”

VA managers, it turned out, had an incentive not to draw attention to the pending files, records and interviews show. Their performance metrics were linked to the success of the online application system and the speed with which veterans were enrolled, according to the records. The Health Eligibility Center (HEC) manipulated data to achieve results linked to these goals instead of focusing on fixing the problems, whistleblowers said.

“They were not going to admit to Congress that they did not have the data to enroll veterans,” Hughes said.

The pending backlog is now the target of an investigation by the VA’s Office of Inspector General and the House Committee on Veterans’ Affairs, chaired by Rep. Jeff Miller, R-Fla.

“VA has a responsibility to facilitate the completion of this mountain of pending applications, and it is clearly not getting the job done,” Miller told the AJC. “It’s time for department leaders to outline a strategy to address this situation or explain to America’s veterans why a backlog of nearly 900,000 pending health enrollment applications is acceptable.”

In an interview Thursday, Philip Matkovsky, the assistant deputy under secretary for health for administrative operations, did not dispute the pending data presented by the AJC. But he said some records in pending status might be a carry over from a previous information system used by the VA and more than a decade old, which could account for some of the records indicating a veteran was deceased. Some may not be applications at all, he said.

He said as a result of the AJC’s questions, he has directed the eligibility staff in Atlanta to devise a plan to contact all veterans with pending applications in the VA system, an idea that Hughes, the whistleblower, said she suggested more than two years ago.

“We need to figure out how to go back and process the entire list of pending applications,” Matkovsky said, “figure out where the veteran resides and get in touch with them and ask them if they want to finish their application.”

Asked about a VA scorecard for managers showing that the success of the online application process was tied to individual performance metrics, Matkovsky said, “You’ll see a lot of stuff on our scorecard. They are operation metrics that allow us to focus…It’s not for performance plans.”

‘Major source of concern’

Nationally, the VA has come under fire for a breathtaking array of problems: veterans who wait months to get an appointment for treatment at a VA health care facility; officials who falsify data to underplay the severity of wait times; managers who ignore problems identified by rank and file employees; an environment where achieving performance metrics and bonuses take precedence over fixing problems; and a bureaucracy where those employees who speak out are punished and retaliated against.

The AJC’s findings fit that pattern and concern a little-known division of the VA bureaucracy called the Health Eligibility Center in Atlanta. The center’s mission is to manage the enrollment and eligibility process for 8.9 million veterans across the VA’s health care system. In a sense, it operates as the gatekeeper to VA health benefits.

In June, the AJC reported that officials at the HEC may have improperly deleted thousands of health care applications from veterans. Scott Davis, a whistleblower identified by the newspaper, appeared before Miller’s committee on veterans’ affairs and testified that hundreds of thousands of applications were also caught in “pending” status.

The latest documents reviewed by the AJC and additional interviews conducted with whistleblowers add fresh details and paint a more ominous picture of the problem. The records include emails, meeting minutes, spreadsheets of the backlog and performance scorecards used by VA. They reveal that administrators knew that the pending backlog could harm veterans by denying them access to VA health care, but did not publicize the problem or seek to resolve it quickly.

The problems with the online application process are linked to how the VA implemented President Obama’s vision to make VA a 21st century organization that treated veterans like clients. When then-VA Secretary Eric Shinseki took office in Jan. 2009, he promised to leverage information technology to “accelerate and modernize services,” according to a VA release announcing his tenure.

A critical player in that agenda was the VA’s Chief Business Office, which oversees the Health Eligibility Center in Atlanta.

The new online application rolled out in August 2010 and removed a signature requirement that veterans had to mail to VA as part of the application.

“This singular action will reduce days, if not weeks, for veterans who apply online to access their hard-earned medical benefits,” Shinseki said at the time.

In January 2012, the VA issued a new policy directive mandating that all health care applications be processed within in five days.

Just months after the directive, the HEC alerted enrollment coordinators at VA hospitals across the country in a conference call that there was a problem handling the caseload, according to minutes of the March 9, 2012, call.

An internal analysis found the number of veteran health applications in “pending eligibility” status had become a “widespread” issue across the VA health system. Eligibility verification had become “a major source of concern,” according to the minutes, and threatened the agency’s mission to provide veterans with timely access to health care.

The pending applications are “mainly the result of inability of HEC to electronically obtain” certain veterans records needed to verify their eligibility, according to the minutes.

“HEC is requesting your partnership in resolving these cases as quickly as possible,” the minutes said.

More than a year later, HEC officials were again on the phone with VA eligibility coordinators to discuss the problem with pending applications. But little had changed.

“These veterans have never received an enrollment decision as a result of this missing data, ultimately delaying access to health care,” HEC officials said on a June 11, 2013, conference call with enrollment coordinators at 152 VA hospitals across the country.

‘It was clear veterans were dying’

The problems were no surprise to Kimberly Hughes or her team at HEC headquarters in Atlanta.

She managed the HEC informatics division charged with analyzing data to identify trends and emerging issues related to enrollment and eligibility across VA’s health system. Hughes said she viewed her job as a calling. Her late father, a World War II veteran who served in France and Germany, relied on the VA for his own health care up until his death in 2000.

In 2011, her analysts spotted an uptick in the number of pending applications. Many of them, roughly 600,000, simply didn’t have an income or means test on file with VA. In about 250,000 other cases — almost a third of those in pending status — VA couldn’t verify the veteran’s eligibility. This group represented the fastest growing segment on the pending list.

“We said, ‘This cannot keep happening,’” Hughes said. “This number is growing at an increasing rate. It’s obvious there is something wrong. There should not be this many pendings.”

Part of the analysis included matching a database containing more than 800,000 veterans in pending status with death records maintained in other sections of VA. The review identified thousands of veterans who died while still in pending status, according to Hughes. Some had been in the system for years, but their presence raised additional concerns that the delays had caused harm.

“It was clear veterans were dying while in pending,” said Hughes. “Did they die because they were in pending? We had no idea. It was obviously something that was happening to veterans.”

Her team found that the online application proved to be the slowest way to enroll in VA health care for many veterans. Their internal analysis, reviewed by the AJC, showed that only one in three online applications met the five-day turnaround rate. A majority of the online applications went into a pending status. About 20 percent remained unresolved and pending two and a half months after the veteran applied.

The online application rolled out with a huge design flaw, Hughes said, because it didn’t allow veterans to upload their discharge papers electronically, usually a DD-214 form. The form is akin to a birth certificate or social security card for veterans that quickly establishes when and where a they served, and for how long. When veterans applied in person at a VA hospital, by contrast, they could bring the form and show it to an enrollment coordinator and quickly get their application processed.

Hughes said the solution her group proposed in the spring of 2012 was straightforward: The HEC needed an outreach campaign to all veterans on the pending list to let them know they needed additional documentation to enroll, and that VA needed to communicate to veterans that applying online without any supporting documents could create enrollment delays.

“Our staff recommended that the Chief Business Office go back and say we do need a DD-214,” Hughes said.

The project to deal with the pending applications was assigned to a deputy director at HEC, Hughes said.

“We never heard from them again,” she said. “They never asked us for any data. They never asked us to come to a meeting. It was just like ‘poof.’ It disappeared into the ether.”

She added, “There was a huge reluctance because no one in government wants to go back and say we made a mistake.”

At no time did any of her superiors express a desire to find out what happened to the more than 47,000 veterans who applied for health care eligibility but appeared to have died before they received it, Hughes said.

A problem that won’t go away

By the fall of 2012, Lynne Harbin, the deputy chief business officer for member services, seemed ready to try to address the pending problem after meeting with her boss, Philip Matkovsky. In an Oct. 12, 2012, email, Harbin outlined the issue as one of several items she wanted to discuss with HEC leadership in a conference call with her leadership team.

But Harbin, whose duties included overseeing the HEC in Atlanta, also faced a problem: HEC data showed that some of the pending applications were filed “years ago.” Her thought about those, according to the email?

“We may not want to call attention to them,” Harbin wrote.

Hughes said it wasn’t the first time Harbin expressed concern about drawing attention to the problem with pending applications. Harbin told the staff she didn’t want the problem to catch the attention of Congress or higher-ups in VA, Hughes said.

“She was worried about it being a scandal,” Hughes said. “If we sent out a half million letters to veterans saying, ‘Oops, we can’t enroll you,’ — that they would contact their representatives.”

What’s more, the VA kept telling veterans that applying online was the fastest way to enroll, Hughes said.

“They knew after our analysis that wasn’t true,” she said.

In early 2013, the HEC still hadn’t gotten to the bottom of the pending application problem.

By that time, Hughes had moved to a different position at HEC. Her former staff told her that the two top officials at HEC had directed them to resolve the pending application backlog simply by rejecting 600,000 applications that required income verification for approval, she said. That solution would allow the HEC to start the new year fresh.

The staff members refused to carry out the directive, Hughes said, because the HEC had no authority to reject veterans who may have been eligible for care.

In telephone interviews with the AJC last week, Harbin said the allegation that she deliberately tried to conceal the extent of the pending application backlog “is not correct.”

“The concern I had was not scandal, but was causing concern for our veterans when they did not really apply for VA care,” Harbin said. “Their families may receive a letter from the VA and they are now deceased without us having that good information for them. So (a) very different concern.”

Harbin also said referring to the more than 800,000 pending applications as a “backlog” was misleading. She said many predate the enrollment system that began in 1998 and are not actually applications. She could not give a specific number of how many records showing up in the pending files were not applications from veterans.

Outreach to clear the backlog

Hughes said she left VA Jan. 24, 2013, after her managers retaliated against her for discovering the pending applications problem. In her last month, she discovered an additional backlog of 39,000 veteran health applications that were waiting to be processed. During the analysis she learned HEC had been manipulating processing dates to hide how long it took to enroll veterans, she said.

Unprocessed applications that were received a month earlier showed a turnaround of three days, Hughes said.

“I fell on the floor. I couldn’t believe it,” she said. “You manage to the metrics. If you have a five-day turnaround time, guess what? It’s three days. Manage to the metrics. That’s the mantra. It has to be good news.”

In May 2013, the center launched a limited outreach campaign to try to address the backlog. They sent letters to 106,000 veterans, limiting it to pending records from fiscal years 2012 and 2013. The letters asked veterans to provide missing information so VA could process their applications.

Around the same time, Matkovsky, whose duties include oversight of the Chief Business Office, HEC and the online application, acknowledged that the online process was the “slowest” way for veterans to get their applications processed.

“It may seem like a small thing, but how quickly we turn around enrollment applications is a significant element in terms of access to care for new veterans,” he wrote on July 3, 2013, in an email to VA regional directors. At the time, less than 50 percent of online applications were processed within the mandated five-day turnaround; now, about 54 percent are being processed within five days, an improvement.

The outreach campaign to clear the backlog has continued this year. VA has mailed more than 200,000 letters to veterans and received 22,000 replies, of which 15,000 have been enrolled in VA health care, Harbin said.

“The majority of the veterans that we’re mailing out to, they are not responding,” Harbin said. “They don’t want to be enrolled. If they did they’d respond. These are not applications. They are records.”

But the total number of pending applications has continued to climb and is now 889,048, according figures VA provided to congressional investigators last month.

And even now, the VA spends roughly $1 million a year to market the online application process to unknowing veterans. The VA website tells them that it’s the “fastest and easiest” way to apply.